Recent estimates show that more than 11% of adults in the United States experience chronic pain, and clinical guidelines indicate that these patients receive appropriate pain treatment only after carefully considering the benefits and risks of drug options. Opioids are commonly prescribed for pain, with about 3% to 4% of U.S. adults being prescribed these agents for long term duration. While these medications can be effective when used for shorter durations, fewer studies have rigorously assessed the long-term benefits of opioids for pain lasting longer than 3 months.
“Opioid use presents a serious public health risk, with data showing that the number of deaths relating to opioid use quadrupled from 1999 to 2010,” says Deborah Dowell, MD, MPH. In 2013, about 1.9 million people abused or were dependent on prescription opioid pain medications. This has led many clinicians, especially those in primary care, to have increasing concerns about opioid pain medication misuse.
A Welcome Update
In 2016, the CDC released its first guideline for prescribing opioids for chronic pain that is intended for use by primary care and family physicians, internists, nurse practitioners, and physician assistants who treat adults (aged 18 and older) with chronic pain in the outpatient setting. Published in the Morbidity and Mortality Weekly Report and available for free at www.cdc.gov, the guideline is intended for use outside of active cancer treatment, palliative care, and end-of-life care. Some of the recommendations might be relevant for acute care settings or other specialists, such as emergency physicians or dentists.
A key goal of the guideline is to improve communication between clinicians and patients about the risks and benefits of opioids for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy. “Clinicians need to balance the risks and benefits for each patient when considering the use of opioids,” says Dr. Dowell, who was lead author of the CDC’s guideline. The recommendations are voluntary standards that were based on emerging evidence from observational studies or randomized clinical trials.
The 2016 guideline includes 12 overarching recommendations, one of the most important being that non-opioid therapies are preferred treatments for chronic pain (Table). “A key overarching theme is to do no harm,” Dr. Dowell says. Before starting opioids, clinicians are recommended to establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks.
Dr. Dowell also says it is critical to prescribe the lowest effective dose possible whenever opioids are used. “Clinicians also need to carefully reassess benefits and risks of opioids when considering increasing the dosage,” she says. “Doctors should evaluate benefits and harms of starting opioids within 1 to 4 weeks of initiating these medications. When continuing patients on opioid therapy, physicians should monitor patients periodically, at least every 3 months, and more frequently in some cases.” The CDC adds that clinicians should review prescription drug monitoring program data for high-risk combinations or dosages.
Management plans to mitigate risks are also recommended by the CDC. Such plans should consider offering naloxone when patients are at increased risk for opioid overdose, such as patients with a history of overdose or substance use disorder, higher opioid dosages, or concurrent benzodiazepine use.
When prescribing opioids for chronic pain, the CDC recommends using urine drug testing before starting these drugs and retesting urine at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs. For patients with opioid use disorder, clinicians should offer or refer patients for evidence-based treatments, such as medication-assisted treatment with buprenorphine or methadone, and arrange follow-up care.
The CDC intends to work with federal partners and payers to evaluate payment reform and healthcare delivery models that could improve patient health and safety. Such strategies might include:
♦ Strengthening coverage for non-pharmacologic treatments, appropriate urine drug testing, and medication-assisted treatment.
♦ Reimbursing time for patient counseling.
♦ Developing payment models that improve access to interdisciplinary, coordinated care.
The CDC will revisit the guideline to determine if evidence gaps have been addressed to warrant an update and revise recommendations accordingly. “Research is needed to improve the current understanding of which types of pain, specific diseases, and patients are most likely benefit and/or be harmed from opioid therapies,” says Dr. Dowell. “Future research should also evaluate and estimate the cost-benefit of non-opioid and multidisciplinary pain interventions. New strategies for identifying and mitigating risks with opioids are also needed to improve patient and public health outcomes.”
Deborah Dowell, MD, MPH, has indicated to Physician’s Weekly that she has or has had no financial interests to report.
Readings & Resources (click to view)
Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016 Mar 15 [Epub ahead of print]. Available at: http://jama.jamanetwork.com/article.aspx?articleid=2503508.
Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. J Pain. 2015;16:769-780.
Gregorian RS Jr, Gasik A, Kwong WJ, Voeller S, Kavanagh S. Importance of side effects in opioid treatment: a trade-off analysis with patients and physicians. J Pain. 2010;11:1095-1108.
Guideline for the use of chronic opioid therapy in chronic noncancer pain: evidence review. American Pain Society and American Academy of Pain Medicine. Available at: http://americanpainsociety.org/uploads/education/guidelines/chronic-opioid-therapy-cncp.pdf.